hallucinations is unusual for intoxication with atropine or scopolamine, but could be explained by delayed digestion of non-ground Jimson weed seeds. Postprandial ‘inability to vomit’, followed by unconsciousness and auditory hallucina-tions, as reported by this patient, clearly is consistent with tropane alkaloid poisoning, and, together with laboratory results (50 seedsD. stramonium/kg of grain), confirm con-tamination by Jimson weed to be the cause of this event.
Foodborne disease outbreaks are recognized by the occur-rence of illness within a variable but usually short time period after a meal, among individuals who have consumed foods in common. Prompt and thorough laboratory evaluation of cases and implicated foods is essential. Food poisoning due to Jimson weed may mimic B. cereus food intoxication and therefore should be considered as a differential diagnosis. The increasing propagation of organic farming with the refusal to use pesticides may increase the occurrence of food poisoning due to Jimson weed in the future.
Conflict of interest:No conflict of interest to declare.
References
1. Anonymous. Foodborne intoxications (food poisoning). In: Hey-mann DL, editor.Control of communicable diseases manual. 18th ed. Washington DC, USA: American Public Health Association; 2004. p. 211—21.
2. Tiongson J, Salen P. Mass ingestion of Jimson weed by eleven teenagers.Del Med J1998;70:471—6.
3. Anonymous. Epidemiologic notes and reports Jimson weed poi-soning–—Texas, New York, and California, 1994. MMWR Weekly
1995;44:41—4.
4. Ruhwald M. A case of poisoning with Jimson weed and alcohol, taken in suicidal intent.Ugeskr Laeger2005;167:2064—5. 5. Busia K, Heckels F. Jimson weed: history, perceptions, traditional
uses, and potential therapeutic benefits of the genusDatura. Herbal Gram2006;69:40—50.
6. Perharic L. Mass tropane alkaloid poisoning due to buckwheat flour contamination.Clin Toxicol2005;43:413.
7. Hermanns-Clausen M. Vergiftungen mit biogenen Drogen–—Fa¨lle aus dem Alltag. Available at:http://www.aerztekammer-bw.de/ 25/08laek/drogen/9.pdf(accessed November 2006).
R. Fretz D. Schmid W. Brueller L. Girsch A.M. Pichler K. Riediger M. Safer F. Allerberger* Austrian Agency for Health and Food Safety (AGES), Spargelfeldstr. 191, A-1220 Vienna, Austria
*Corresponding author. Tel.: +43 (0) 505 55 35500; fax: +43 (0) 505 55 25802 E-mail address:Franz.Allerberger@ages.at (F. Allerberger)
Corresponding Editor:William Cameron, Ottawa, Canada
15 January 2007
doi:10.1016/j.ijid.2007.03.003
Antimicrobial resistance among urinary tract
Escherichia coli
isolates from inpatients and
outpatients in a tertiary care center in Sa
˜o
Paulo, Brazil
Urinary tract infections (UTIs) having pathogenicEscherichia colias the etiologic agent, remain a common and troublesome health problem in many countries, resulting in considerable morbidity and costs.1Non-complicated infections, particularly in women, account for the highest number of UTIs. Women diagnosed with acute uncomplicated cystitis are usually trea-ted as outpatients; the microbiologic characteristics of this infection are highly predictable even in otherwise healthy subjects. Physicians have therefore been advised that empiri-cal antimicrobial treatment not requiring culture is appropri-ate in such cases. This empiric therapy has been widely employed and fewer UTI germs are now routinely cultured. However, increasing antibiotic resistance of uropathogens causing both community- and nosocomially-acquired UTIs has been clearly demonstrated.2,3
Different levels of population treatment exist within the health system in Brazil. ‘Primary care’ takes place at the municipal health center (essentially a doctor’s office), ‘sec-ondary care’ is performed at the municipal hospitals, and the ‘tertiary care’ system essentially takes place at university teaching hospitals. Within these systems, updated
knowl-edge of causal bacteria and their susceptibility patterns is important for the proper selection and use of antibiotics, as well as for an appropriate prescribing policy. We conducted a study to verify the antimicrobial resistance ofE. coliamong UTI isolates from the ‘primary care’ and ‘tertiary care’ systems in Ribeira˜o Preto, Sa˜o Paulo, Brazil.
The antimicrobial resistance profile infection data obtained from the Clinical Hospital of the School of Medicine of Ribeira˜o Preto (HCFMRP), a university teaching hospital, and from municipal health centers, concerningE. coli iso-lated from UTI patients, were monitored and analyzed. Isolates were collected between July 2000 and July 2003. A total of 67 strains ofE. coliisolated from HCFMRP and 78 strains from the municipal health centers were analyzed. The isolation and identification ofE. colistrains was performed by minimal standard bacteriological tests using conventional biochemical markers;4one isolate per patient was evaluated. Antimicrobial susceptibility was determined by the Kirby— Bauer disk diffusion method following the definitions of the National Committee for Clinical Laboratory Standards (NCCLS) for agar diffusion tests5using antibiotic-containing
disks (CEFAR Diagnostica Ltd, Sa˜o Paulo, Brazil). Quality control was performed usingE. coliATCC 25922.
Tests on the susceptibility ofE. coli isolates to antimi-crobial drugs showed that the highest rates of resistance were found among those from the hospital patients, with resistances at least twice as high as those of the isolates
from the municipal health centers. Resistance was highest to tetracycline (73.0%), ampicillin (65.0%), cephalothin (58.0%) and trimethoprim/sulfamethoxazole (TMP/SMX, 58.0%) (Table 1). In spite of the high potency of fluoroqui-nolones againstE. coliisolates, a relatively high resistance to norfloxacin was observed: 31.0% in the hospital and 12.0% in the municipal unit patients (Table 1).
UTIs are one of the most common infectious diseases diagnosed in outpatients as well as in hospitalized patients. Susceptibility to antimicrobial agents among hospitalized patients3,6 and among outpatients7,8 has been shown. The rates we report in the present study for patients from the hospital agree with those reported by Gales et al.3in anti-microbial surveillance studies in Latin American hospitals including some from Brazil, but are higher than those reported for Canadian6hospitalized patients.
Many factors may have contributed to such high rates of resistance including misuse of antibiotics by healthcare pro-fessionals or non-skilled practitioners, misuse of antibiotics by the general public (antibiotics can be purchased in Brazil without a prescription), and inadequate surveillance due to a lack of information arising from routine antimicrobial sus-ceptibility testing. The resistance rates to isolates from the municipal health centers reported in the present study are higher7or lower8than those reported in other studies; how-ever, in all of these other studies, the reported rate of fluoroquinolone resistance was lower than that observed in the present study.
In agreement with the high rates reported in the present study, a significant increase in resistance of uropathogenic strains to TMP/SMX, ampicillin and cephalothin has been found worldwide;9 therefore, these agents are in general not recommended for first line empirical treatment of UTIs. Therapies other than those described above may have to be taken into consideration in Brazil, possibly using older agents like gentamicin and nitrofurantoin that still show high effi-cacy against UTI pathogens.
In conclusion,E. coliisolated from hospital or municipal health center UTIs are to a significant extent resistant to many antimicrobial agents. The use of TMP/SMX, ampicillin
and cephalothin against uropathogens has to be re-exam-ined. Also, the high resistance rates to fluoroquinolones in Brazil gives rise to concern. Regular monitoring of antimi-crobial drug resistance appears necessary to improve our guidelines for empirical antibiotic therapy.
Conflict of interest:No conflict of interest to declare.
References
1. Foxman B. Epidemiology of urinary tract infection: incidence, morbidity and economic costs.Am J Med2002;113:S5—13. 2. Gupta K, Hooton TM, Wobbe CL, Stamm WE. The prevalence of
antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in young women.Int J Antimicrob Agents 1999;11:305—8.
3. Gales AC, Jones RN, Gordon KA, Sader HS, Wilke WW, Beach ML,
et al.The Sentry Study Group (Latin America). Activity and spec-trum of 22 antimicrobial agents tested against urinary tract infec-tion pathogens in hospitalized patients in Latin America: report from the second year of the SENTRY Antimicrobial Surveillance Program (1998).J Antimicrob Chemother2000;45:295—303. 4. Farmer JJ.Enterobacteriaceae: introduction and identification.
In: Murray PR, Baron EJ, Phaller MA, Tenover FC, Yolken RH, editors. Manual of clinical microbiology. 7th ed. Washington, D.C.: ASM Press; 1999.
5. National Committee for Clinical Laboratory Standards. Perfor-mance standards for antimicrobial disk susceptibility tests. Approved standards M2-A7. 7th ed. Wayne, PA: NCCLS; 2000. 6. Zhanel GG, Karlowsky JA, Harding GK, Carrie A, Mazzulli T, Low DE,
et al.A Canadian national surveillance study of urinary tract isolates from outpatients: comparison of the activities of trimethoprim— sulfamethoxazole, ampicillin, mecillinam, nitrofurantoin and ciprofloxacin.Antimicrob Agents Chemother2000;44:1089—92. 7. Karlowsky JA, Kelly LJ, Thornsberry C, Jones ME, Sahm DF. Trends
in antimicrobial resistance among urinary tract infection isolates ofEscherichia colifrom female outpatients in the United States. Antimicrob Agents Chemother2002;46:2540—5.
8. Lee SJ, Lee SD, Cho IR, Sim BS, Lee JG, Kim CS,et al.Antimicrobial susceptibility of uropathogens causing acute uncomplicated cysti-tis in female outpatients in South Korea: a multicentre study in 2002.Int J Antimicrob Agents2004;24S:S61—4.
9. Hooton TM. Fluoroquinolones and resistance in the treatment of uncomplicated urinary tract infection.Int J Antimicrob Agents 2003;22:S65—72.
Edilene Santoa a
Department of Microbiology, Julio de Mesquita Filho — UNESP University, Jaboticabal, Sa˜o Paulo, Brazil
Miriam Mendonc¸a Salvadorb Jose´ Moacir Marinb,* b
Departament of Morphology, Stomatology and Physiology — FORP, Sa˜o Paulo University, Campus Ribeira˜o Preto, Brazil
*Corresponding author. Tel.: +55 016 6024101; fax: +55 016 6330999 E-mail address:jmmarin@forp.usp.br (J.M Marin)
Corresponding Editor:Timothy Barkham, Singapore
21 March 2006
doi:10.1016/j.ijid.2006.10.007
Letters to the Editor 559
Table 1 Antimicrobial resistance ofEscherichia coliisolates from a tertiary-care teaching hospital and municipal health centers in Brazil
Antibiotic Resistance (% of isolates)
Hospital (67 strains)
Municipal health centers (78 strains)
Ampicillin 65.0 37.0
Cephalothin 58.0 8.0
Cefoxitin 24.0 0.0
Cefuroxime 18.0 1.0
Ceftriaxone 6.0 1.0
Gentamicin 13.0 0.0
Tobramycin 22.0 3.0
Tetracycline 73.0 31.0
Norfloxacin 31.0 12.0
Nitrofurantoin 18.0 5.0
Trimethoprim/ sulfamethoxazole
